The transgender community: Urology has a role and responsibility
I was in the San Diego airport on the way home from the AUA annual meeting when I noticed signs for the restrooms. To one side was a sign showing a stick-figure man with pants and on the other side a stick-figure woman with a skirt. What caught my eye was the door in the middle, where I expected to find the family restroom (I’ve become facile at locating this one given my troupe of little ones). Instead of a “Family Restroom” sign, this sign included a stick-figure man, a stick-figure woman, and then a stick figure that had one leg in slacks and the other in a skirt.
It was the first time I had seen a restroom specifically designated for the transgender community.
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I'll concede that my first reaction was a small chuckle and the thought, "Ahh, California." But I quickly realized that people may have the same reaction getting off a plane in Denver where they immediately see a bright green cross for a recreational marijuana dispensary or even getting off a plane in Las Vegas and seeing a dozen slot machines.
An hour later, as I was waiting for my delayed flight, I thumbed through the AUA program to pull up abstracts of interesting posters or podiums I missed. I came across a section on pediatric urology and more specifically disorders of sexual differentiation, and my thoughts turned back to that restroom. I then went to the AUA website and to the best of my ability, could find no white paper, consensus statement, or policy endorsed by the AUA on bathrooms and the transgender community. That bothered me.
This debate has gained much recent attention after the North Carolina legislature in a special session passed a law that bars people statewide from using bathrooms that do not match the gender listed on their birth certificate. The law was passed in response to a law passed in the city of Charlotte, which provides protections based on sexual orientation, gender expression, and gender identity, including specifically letting transgender people use the public bathrooms that correspond with their gender identity, not necessarily the gender listed on their birth certificate.
Politics aside, and whether or not we even like it, all of us who have gone through a urology residency have spent hours memorizing the steroid pathway and have been grilled on the manifestations and implications of specific inborn errors of metabolism such as congenital adrenal hyperplasia (CAH). Most of us only had to deal with this in residency, although I'm sure a certain percentage had the pleasure of discussing the topic with a certifying examiner in Dallas—a much more anxiety-provoking scenario.
Further, even small-town plumbers like me have done cystoscopies on women with penises, and we've all been called to the NICU to examine a newborn baby with a severe case of CAH whose gender was nearly impossible to determine—a boy with a small penis and bilaterally undescended testicles or a masculinized girl with clitoromegaly? To this day, I have no idea how physicians decide what gender to write on the birth certificate in situations like that.